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The purpose of the Governance, Administration, and Management (GAM) section is to provide a framework of tools by
which a Clinic’s Governing Body ensures accountability, fairness, and transparency of the organization. The Standards
describe mechanisms, which promote a Clinic’s duty to enhance living its mission, monitoring meaningful impact on
current and future healthcare gaps, and ensuring viability of the organization. Additionally, these Standards describe the
criteria for directors and managers to efficiently administer a Clinic’s operations.
A Clinic's Mission Statement clearly communicates services provided, by whom and to whom. A good Mission Statement
includes rationale for the clinic, any guiding principles, and must be clear, memorable, and concise. Goal Statements
provide direction for planning, evaluating plans, and guiding projects and actions.
2. A Clinic's Mission Statement Section of Mission Statement verifying At least one of the healthcare needs in the
addresses a documented, compliance to this standard. Mission Statement is identified in the most
current community recent Community Health Needs Assessment
healthcare service need. Section of documentation verifying (CHNA).
community healthcare service need;
including date of documentation Mission does not inappropriately duplicate
*Current = within 3 years of publication. other community programs serving the same
today’s date need and/or population without
demonstrated need or deficit in
care/program.
3. A Clinic's identified Goal Section of Goal Statement verifying Governing Body Meeting Minutes verifying
Statements are consistent compliance to this standard. approval of Goal Statements.
with its Mission Statement
and are specific, Strategic Plan links program(s) to Mission
measurable, acceptable, Statement and Goal Statements.
realistic, and time-bound
(S.M.A.R.T. goals).
* If original policy cannot be located, Governing Body re-reviews and meeting minutes illustrate the approval
process for stated standard.
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GAM1b. Legal Document Standards
These Standards describe minimum legal accountability for a Clinic. The information contained in the Legal Document
Standards is not intended to serve as legal advice nor should it substitute for legal counsel.
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GAM1c. Governance Standards - CONTINUED
10. A Clinic’s fundraising practices Copy of fundraising policy or description of Profile on Guidestar.org.
follow the Association of customary practice.
Fundraising Professionals Code of
Ethics.
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GAM1d. Financial Standards - CONTINUED
The purpose of the Operational Competency Standards is to identify those organizational functions, which contribute to
an efficiently run clinic, meet required legal statutes for employees and show effective volunteer engagement.
14. A Clinic has a current Employee Employee Handbook showing: Verification of annual review of Employee
Handbook. Handbook by director.
accessible to all employees
section on overtime Verification of employee notification of
expectations changes to Employee Handbook.
verification of receipt upon hire.
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GAM2a. Employee Management - CONTINUED
16. A Clinic reviews current licensure Job Descriptions include licensing and
to practice. credentialing criteria as appropriate.
Confirmation of credentialing is
documented.
17. A Clinic conducts background Signed Employee’s consent to conduct a Extensive criminal background check
checks on all employees. criminal background check. completed including arrest records.
18. A Clinic withholds payroll taxes in Current Federal IRS Form W-3. Annual notice is provided to employees
accordance with federal and about changing Form W-4 if change in
state regulations. Current IRS Form W-4 signed by address or withholdings occurs.
employee.
A new Form W-4 when employee personal
Current year’s quarterly IRS Form 941s. or financial situation changes.
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GAM2b. Volunteer Management
20. A Clinic conducts criminal Signed Volunteer’s consent to conduct a Extensive criminal background checks
background checks on all criminal background check. completed including arrest records.
volunteers that will be on the
premises when there are Documentation indicates online search
patients or children present. through Wisconsin Circuit Court Access on
volunteer background.
21. A Clinic has a current Volunteer Written Volunteer Manual is available to all Volunteer Manual receipt and agreement
Manual. volunteers. to adhere signed annually by volunteers.
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GAM3. Risk Management
The goal of the Risk Management Standards is to reduce risks to the clinic and ensure individual safety by identifying
high risks and defining methods to avoid risk. Sources of risks to organization and individuals include but are not limited
to financial viability, liability, organizational practices, and patient sources. All members of the Clinic are responsible to
provide safe care and ensure safety processes.
Note: The Standards in this section are intended for application in clinics that dispense medications legally requiring a
medical prescription from an on-site dispensary and/or pharmacy. These Standards refer to medication prescriptions
that are not classified as controlled substances as determined by the Drug Enforcement Act and the Food and Drug
Administration. Refer to federal- and state-specific mandates for proper licensing and dispensing of these controlled
substances.
27. A Clinic’s staff demonstrate Provides medications under the license of a Documentation of Clinician’s review of
safe and effective clinical healthcare provider with current prescriptive medical history, including allergies,
decision-making about authority. adverse drug reactions, medication list
patient care and therapeutic and recent laboratory testing at every
options. Pharmacist or appropriate staff documents in visit.
medical record patient’s medication history,
including allergies, adverse drug reactions, and
contraindications with current prescriptions at
every visit.
28. A Clinic has a process to Hand-written prescriptions are legible. If clinic has EMR will use E-prescribing
ensure clear, accurate to communicate new and renewed
communication of Oral orders are only given in an emergency prescriptions to the pharmacy.
prescription information to situation and are verified as soon as possible by
pharmacist or other staff. written order.
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GAM3a. Medication Management- CONTINUED
29. A Clinic prepares and Pharmacist or other with authority to dispense Pharmacist or appropriate clinical staff
dispenses medications in medications labels all dispensed medications as enters prescription order into
accordance with all applicable required by law. pharmacy database system.
federal, state, and local laws
and regulations and gift in- Medication samples are dispensed in original
kind donor mandates, if manufacturer’s sealed packaging; Med 17.04.
applicable.
Documented in the medical record when
dispensing medications.
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GAM3a. Medication Management- CONTINUED
31. A Clinic routinely assesses Documentation of assessment and adherence Record of report of medication adverse
therapeutic response to level and barriers to safe and effective self- effects to FDA.
medication therapy. administration of medications in the medical
record.
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GAM3b. Environmental Safety
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GMA3c. Transmission of Bloodborne Pathogens and Communicable Disease
GAM3d. Liability
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GAM3d. Liability - Continued
35. A Clinic maintains additional Receipt for coverage via annual malpractice
malpractice coverage through insurance through insurance carrier.
the WI Injured Patient and Families
Compensation Fund
(or “the Fund”) as applicable
per state regulations.
36. A Clinic provides professional Records indicate all licensed clinic Meeting minutes from Governing Body
liability (medical malpractice) employees/volunteers are registered with or attorney review of
insurance and Directors and VHCP or FTCA/HRSA. VHCP or FTCA/HRSA coverage to
Officers liability insurance which determine if additional coverage is
includes employment practices Clinic files verify registration is maintained and needed; such as Professional Liability
liability protection. renewed with VHCP or FTCA/HRSA. Coverage or Board and Directors
Coverage.
Copy of Professional liability coverage for staff
and volunteers not covered Professional liability coverage for
VHCP or FTCA/HRSA. Executive Director and paid staff.
Copy of Directors and Officers insurance A fidelity bond and/or commercial crime
coverage declaration page or paid invoice. insurance, with liability limits no less
than the maximum amount of cash and
cash equivalents on hand at any point in
the year, for acts of dishonesty by staff,
volunteers, and board members with
financial duties is also provided.
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GAM3e. Patient Information Security
The purpose of the Performance Management Standards is to help clinics identify elements of a performance
improvement program, which utilizes best practice guidelines to enhance the quality of care delivered to the free or
charitable clinic population.
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Standard Required Evidence Optimal Evidence
38. A Clinic implements quality Clinic meeting agenda and meeting minutes on A Quality Improvement Plan based on
improvement practices. quality improvement practices. the evaluation of data approved by the
Clinic’s Governing Body.
Identify and implement at least one
performance improvement activity per year.
40. A Clinic measures patient Periodic report of patient experience and A written plan to improve patient
experience. feedback collected through surveys, phone experience based upon the patient
calls, or other means. experience report.
41. A Clinic records “basic” patient Medical record collects patient data to include Collect patient data for at least one of
information in a medical all elements of the CCDA (Consolidated Clinical the following measures or similar:
record. Document Architecture):
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